Aggressive End-of-Life Care More Likely in ICD Users with Advanced Cancers

Nearly half of patients with an ICD had a device programming encounter near the end of life, which could present an opportunity to discuss goals of care.

End-of-life care was more aggressive for patients with advanced cancers who had implantable cardioverter defibrillators (ICDs) than for those who did not, according to findings from a retrospective analysis study published in Cancer.1 Additionally, nearly half (45%) of patients with ICDs had ICD-related programming or interrogation visits, with another 26% appearing for ICD-related monitoring visits, which could serve as an opportunity to discuss goals of care and device deactivation.

Results from the study found that patients with advanced cancers who had ICDs were more likely to receive more aggressive end-of-life care in all areas than those without one except for end-of-life chemotherapy (4.0% vs 5.7%; P <.001). Notably, patients with an ICD were more likely to receive an invasive procedure (odds ratio [OR], 1.23; 95% CI, 1.22-1.36) or undergo a life-extending procedure (OR, 1.27; 95% CI, 1.11-1.46) than patients without an ICD in the last month of life.

“We know that many people who have cancer are also dealing with other medical problems concurrently, including heart arrhythmias,” lead study author Megan Mullins, PhD, MPH, assistant professor in the Peter O’Donnell Jr. School of Public Health, the Harold C. Simmons Comprehensive Cancer Center, and the Department of Internal Medicine at UT Southwestern Medical Center, said in a news release on the study.2 “By putting these heart devices on cancer specialists’ radars, we can help them start having conversations with patients who have them to make sure their end-of-life care matches their stated wishes.”

The study used Medicare claims data linked to population-based Surveillance, Epidemiology, and End Results (SEER) cancer registry data for cases diagnosed between 2005 and 2015. Patients with breast, colorectal, or pancreatic tumors who died between 2005 and 2016 were selected for analysis. Additionally, the sample was restricted to patients who were 66 years or older to better ascertain comorbidities before diagnosis.

A total of 37,306 decedents with stage III or IV cancer at diagnosis were identified, of whom 2117 (6%) had an ICD device. Furthermore, of those with an ICD, 1323 (63%) had the device prior to cancer diagnosis, and the median time from first ICD claim and death was 35.7 months (IQR, 17.5-59.2). Furthermore, ICD users were predominantly female (55%), non-Hispanic White (83%), and resided in a census tract with less than 20% of the population in poverty (more than 80%).

The median age of patients with cancer who had an ICD was 79 years vs 76 for those without one (P <.001). Most patients with an ICD were diagnosed at stage III (60%) and had a Charlson score greater than 2 (59%). Additionally, median overall survival for patients with an ICD was 19.9 months (IQR, 7.4-46.7) vs 13.7 months (IQR, 6.0-30.5) for those without one (P <.001).

The study end points included aggressive end-of-life care prevalence, ICD utilization, and ICD-related care utilization presenting opportunities to discuss end-of life implications.

Additional data from the study reveal that patients with ICDs had higher adjusted end-of-life hospital utilization odds, including for more than 1 emergency department visit (OR, 1.16; 95% CI, 1.01–1.32), more than 1 hospitalization (OR, 1.20; 95% CI, 1.03–1.39), an intensive care unit stay (OR, 1.17; 95% CI, 1.06–1.30), and dying in the hospital (OR, 1.27; 95% CI, 1.15–1.40).

According to the news release, Mullins described that doctors caring for patients with terminal cancer who have ICDs should help them manage their devices, including the possibility of device deactivation, when undergoing end-of-life care. She further explained that future research will explore the association between ICD prevalence and aggressive end-of-life care.

References

1. Mullins MA, Wang T, Shahan K, et al. Implantable cardioverter defibrillators in people dying with cancer: A SEER-Medicare analysis of ICD prevalence and association with aggressive end-of-life care. Cancer. 2024;131(1):e35640. doi:10.1002/cncr.35640
2. End-of-life care more aggressive for cancer patients with defibrillators. News release. UT Southwestern Medical Center. January 8, 2025. Accessed January 10, 2025. https://tinyurl.com/55m4smtu